History of Present Illness (HPI)

This guide addresses the ‘S‘ubjective portion of a Problem-Focused SOAP Note.

Primary History

1. Location/Radiation
   
2. Quality/Severity
   
3. Duration (total/episode)/Frequency
   
4. Aggravating/Relieving Factors
   
5. Associated Symptoms/Effect on Function
   

Pearls

• Note that these elements are paired to make them easier to remember.
  
• Repeat this series of questions for each concern. Ask one question at a time; avoid multi-part questions.
  
• Some questions won’t work in certain situations, for example fatigue doesn’t have a location.
  
• Record the information as objectively as possible without interpretation. Avoid medical jargon unless the patient uses it.
  
• Quote the patient directly as needed, "my teeth itch," for example.
  
• There are two durations to consider: the total illness and, if symptoms are episodic, the duration of a typical episode.
  
• Pay close attention to the time course of the symptoms. Has the symptom complex changed over time? This is particularly important with neurologic, chest, and abdominal diseases.
  

Secondary History

Tertiary History

The tertiary history brings in elements of the Past Medical, Social and Family History that have bearing on the patient’s condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. (This will be fine tuned by the physical exam.) Here are some examples:

Any HEENT or Chest Disorder
Does the patient smoke? How much? How long?
For children, does someone smoke in the home?
High Blood Pressure
How much alcohol does the patient consume?
Breast Problems
Is there a family history of breast cancer?
Depression
Has the patient attempted suicide in the past?
Has the patient been hospitalized in the past?
Abdominal Pain
Does the patient smoke? How much? How long?
How much alcohol does the patient consume?
Prior surgery? Has the appendix been removed?
Chest Pain
Does the patient smoke? How much? How long?
Did the patient’s parents die of a heart attack? At what ages?
Note: I created this guide in 1996 to assist students who were learning the basic medical interview. I’ve refreshed it here for a new generation of learners. RR

Richard Rathe
Dr. Rathe joined the University of Florida in 1990 to develop the informatics program for the College of Medicine. Prior to his arrival, he completed a two year informatics fellowship at the Harvard School of Public Health. More. Follow me on Twitter!

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